1Department of Pediatrics, Geneca University Hospitals, Geneva, Switzerland, 2Institute of social and preventive medicine, Faculty of Medicine, University of Geneva, Institute of social and preventive medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland, 3Private general practice, Private general practice and school health service, Nyon, Switzerland, 4School Health Service , Department of Public instruction Geneva, Geneva, Switzerland, 5Faculty of medicine University of Geneva, Faculty of medicine University of Geneva, Geneva, Switzerland, 6Department of Pediatrics, University hospitals Geneva, Geneva, Switzerland.

Country - ies of focus

Switzerland

Relevant to the conference tracks

Advocacy and Communication

Summary

This study aims to describe immunization status at first visit in a collective of young people coming to an academic youth clinic. Results confirm our hypothesis that many young immigrants have had adequate childhood vaccination especially for tetanus but are missing Hepatitis B and HPV. Collaboration between nurses in the youth clinic and school health services allows, not only detection of under-vaccinated youth, but quick and effective vaccination .

Background

Adolescents are under-vaccinated and have limited access to effective care or preventive services in many regions of the world. Data on immunization status of adolescents or young adults in Switzerland are scarce and little is known about barriers to adequate coverage. Swiss vaccination coverage data shows that children of foreign origin are usually better immunized, but that this difference is lost in adolescence, where the most important factor of adequate vaccination is the presence of a school health vaccination program.

Objectives

The objective is to describe the immunization status at first visit and differences in immunization status according to duration of stay in Switzerland and nationality of young people coming to a mulitdisicplinary youth clinic in Geneva

Methodology

Immunization status at first visit (medical file, immunization booklets or school health database) was collected retrospectively between January 2010 and June 2011 in all patients coming for a first visit at Geneva University hospital’s multidisicplinary youth clinic. The main outcomes were Tetanus antibody titers one month after a booster of tetanus containing regimen and immunization status at first visit and the comparing of rates between young people of Swiss or foreign origin and for foreigners according to duration of stay in Switzerland.

Results

89% of patients tested for tetanus antibodies had values above 1000 U/l indicating adequate childhood immunization with 29% above 10’000 U/l putting them at risk of hyperimmunization if given usual adult catch up regimens (3 dosis). On the contrary Hepatitis B serology was often negative among the same population in our sample. Finding written information about immunization is significantely higher in youth born in Switzerland regardless of sex and nationality for all vaccines studied (tetanus, measles, hepatitis B and HPV) but is inferior to Swiss vaccination coverage data. Collection of information was highly facilitated by collaboration between academic youth clinic and school health services.

Conclusion

In the absence of data, many young people immunized against tetanus or measles might in fact already be well immunized for childhood vaccinations. Effective collaboration between school-health services, primary health care facilities and youth clinics is highly effective in improving adolescent vaccine coverage especially with the help of public heath policies. School health services are usually very well informed about vaccination strategies in countries of immigration and the WHO database can also help to adapt recommendations to migratory flows. However, they might miss young people at higher risk of being under or over immunized for example those with no booklet, absent from school on the day of immunization campaign, or with no permanent address. In Switzerland, parental consent is required for Hepatitis B or HPV immunization for young people under 16 years of age.Individually adapted catch-up immunization plans for adolescents and young adults regardless of origin or gender can avoid unnecessary and unsafe vaccination, and bring attention to barriers to adolescent vaccination as well as other adolescent health issues. Individual counseling allows targeted screening for silent infectious diseases (STI’s, Hepatitis, Chagas disease or common parasitic infections) but should mainly focus on assessment of protective and risk factors for healthy development of young people.

Medication use review (MUR) is a service provision with accredited pharmacists undertaking structured adherence-centered reviews with patients on multiple medications, particularly those receiving medications for long-term conditions. The overall goal of MUR is to maximize an individual patient’s benefit from their medication regimen and prevent drug-related problems. MUR service is not yet established in community pharmacies in Qatar and nothing is known about pharmacists' knowledge, attitude, and practice pertaining to this service.

Background

In Qatar, most patients currently receive their medications from the 8 public hospitals under Hamad Medical Corporation (HMC). In spite of being secondary and tertiary hospitals, most patients prefer to obtain their care including outpatient pharmacy services from these hospitals. Owing to this preference and attitude, there is unwarranted overcrowding in most hospitals and their outpatient pharmacies within HMC. One of the goals of Qatar’s National Health Strategies 2011-2016 is to improve the health services to international standards. Under this premise, Qatar envisions to provide world-class health care standard services and the best healthcare in the Middle East region (NHS 2011-2016). Within this goal, there is a community pharmacy strategy project aiming to adopt and implement international community pharmacy services and best practices as benchmark. Medication use review (MUR,) is one of these services. MUR service is not yet established in community pharmacies in Qatar and nothing is known about pharmacists' knowledge, attitude, and practice pertaining to this service. To our knowledge, the current study is the first one carried out to investigate the potential impact of implementing MUR services.

Objectives

The overall aim of this research was to evaluate the perception of community pharmacists towards establishing MUR service as an extended role in patient care. The specific objectives of the study are to: 1) Assess the availability of facilities to support MUR implementation in community pharmacies in Qatar; 2) Evaluate pharmacist's self-perceived competence in providing MUR service; 3) Assess the knowledge of community pharmacists on MUR; 4) Assess the practices of the community pharmacists pertaining to MUR.

Methodology

A cross-sectional study using self-administered questionnaires as a research tool was conducted among community pharmacists in Qatar from December 2012 to January 2013. The survey evaluated the pharmacists' self-perceived competence and attitudes towards providing MUR services in Qatar. The study involved pharmacists practicing in the private community pharmacy setting. There are approximately a total of 500 community pharmacists practicing in Qatar. In order to achieve a confidence level of 95% and 5% margin of error, a random sample of 220 community pharmacists currently practicing as community pharmacists in different cities and different pharmacies, including chains and independent pharmacies, in Qatar were selected to participate in the study. Inclusion criteria for potential respondents was: 1) being licensed as a practicing pharmacist in Qatar; 2) Currently working as a community pharmacist and; 3) working in a community pharmacy in Qatar for at least 12 months. The research instrument was developed via review of the literature pertaining to MUR, consultation with experienced researchers, experts, and licensed community pharmacists involved in the service. The data collected were analyzed using IBM Statistical Package for Social Science (IBM SPSS® Statistics) version 20 for analysis. Both descriptive and inferential statistics were used for data analysis. The study was approved by the Institutional Review Board of the Supreme Council of Health, Qatar.

Results

One hundred and twenty-three community pharmacists responded to the survey, but 116 were included in the analysis (useable rate 94%; 116/123). The mean total knowledge score was 71.4% ± 14.7%. Although, nearly all of the participants (97%) were able to identify the scope of MUR in relation to chronic illnesses and in enhancing the quality use of medicines, only 43.4% knew that acute conditions are not the principal focus of MUR services. Over 80% of the community pharmacists were able to identify patients of priority for inclusion in an MUR program. At least 95% of the participants acknowledged that provision of MUR services is a great opportunity for the extended role of community pharmacists and that MUR makes excellent use of the pharmacist's professional skills in the community. Participants generally reported concerns about time, dedicated consultation areas, and support staff being significant barriers towards MUR. A large proportion of the participants (95%) indicated that training and education should be conducted for community pharmacists before implementing MUR program.

Conclusion

The current findings suggest that community pharmacists in Qatar had sufficient knowledge about the concept of MUR and its scope, but there were still important areas of deficiencies and misconception of the practice that warrant education and training. The findings have important implications for policy and practice, particularly pertaining to the implementation of MUR services as an extended role of pharmacists and as part of Qatar's National Health Strategy 2011-2016 agenda to move primary health care forward in Qatar.

Although migration of human resources for health (HRH) is common, the consequences of it for ‘source’ countries are poorly understood, as are the range of strategies implemented to manage these consequences. A study of ‘source’ country perspectives on HRH migration, funded by the Canadian Institutes of Health Research, was conducted in India, Jamaica, the Philippines and South Africa to address this gap. This paper reports the findings from Jamaica, where HRH migration is common, and the causes of it are numerous, long-standing, and systemic. Several strategies have been implemented to address the consequences of HRH emigration from Jamaica, however their impacts have not been studied.

Background

The migration of highly skilled health professionals from developing to developed nations has increased dramatically in the last ten years in response to a range of social, economic and political factors. The consequences of this shift in human resources for health (HRH) can be of critical importance to the overall sustainability of health systems in many of these ‘source’ countries, and have become much more salient in the ongoing debate about the reliance of some high-income countries on health workers who migrate from low- and middle-income countries. Few studies have examined these trends and their consequences from a comparative approach; those that have typically focus on ‘macro-‘level health indicators which do not allow for a broader investigation of the range of impacts HRH migration may have on patients, providers and health systems. Further, existing evidence is almost exclusively limited to physicians and nurses without considering the roles of other highly skilled health professionals who are also critical to the sustainability of developing health systems. Research to date has also given less attention to the range of responses that various policy decision-makers can and have undertaken to stem the tide of emigrating workers, and on their respective impacts.

Objectives

To help to address the above gaps in evidence, a study was undertaken to examine the causes, consequences and responses to HRH migration from four ‘source’ countries – India, Jamaica, the Philippines, and South Africa. Although designed, initiated and overseen by a team of Canadian researchers, the study was largely driven by partners ‘on the ground’ in each of the four participating countries.The research questions the study sought to answer include:
(1) What is the present picture of /recent historic trends in the migration of highly skilled health personnel from Jamaica, the Philippines, India, and South Africa? (a) Who is migrating, how, and why? (b) What are the levels and impacts of return migration? (2) What, according to various stakeholders ‘on the ground’ in these source countries, are the most critical consequences of the migration of highly skilled health workers? (3) What is the range of policy responses that have been considered, proposed and implemented to address the critical causes and consequences of health worker migration from these countries, and what have been some of the outcomes of these responses?In addition to physicians and nurses, each participating country selected two additional categories of HRH to be the focus of their investigations. The purpose of this presentation is to share the study’s findings from Jamaica, where the additional professions selected were midwives and dental auxiliaries

Methodology

The study built on a long-standing successful HRH research partnership between Dalhousie University and the Jamaica Ministry of Health. There were three data collection activities used to address the research questions: a scoping review, key informant interviews, and a survey of Jamaica’s dental auxiliaries, midwives, nurses and physicians. The scoping review identified and synthesized the published peer-reviewed and grey literature on Jamaica as it pertained to the research questions. The initial draft of the scoping review was completed by Canadian members of the research team, reviewed by Jamaican stakeholders for completeness and accuracy, and then updated to address identified gaps. Twenty seven key informants, representing Jamaica’s Ministry of Health, regional health authorities (RHAs), professional colleges and associations, private and public hospitals, universities, the Pan American Health Organization, and the Statistical Institute of Jamaica, were interviewed by the Jamaican study coordinator. The interviews were transcribed, validated by the interviewees, and then subjected to thematic analysis with NVivo 10. The survey of health care professionals was administered using both web and paper based versions. Respondents could choose their desired format. Survey data were subjected to descriptive and regression analysis using SAS 9.2.Preliminary findings from the scoping review and qualitative and quantitative analyses were presented at a deliberative forum at the University of the West Indies (UWI) campus outside Kingston, Jamaica. Participants represented Jamaica’s Ministry of Health, Ministry of Labour and Social Security, Ministry of National Security, and Ministry of Foreign Affairs, each of the four targeted health professions, the RHAs, UWI, private hospitals, Passport and Immigration Services, the Statistical Institute of Jamaica and the Planning Institute of Jamaica. Participants validated the study findings and deliberated several potential strategies to mitigate the negative impacts of migration on Jamaica’s health care system. These findings were subsequently shared with representatives of the other participating countries at an international forum to identify common challenges and potential solutions.

Results

Data on HRH migration are not systematically captured in Jamaica. Migration rates for physicians are estimated at between 31% and 58%, and 66% for nurses. Over one third of respondents from each profession reported that it was very likely they would emigrate within the next five years.Asked why they would emigrate, the top three working conditions-related reasons were income, infrastructure at work, and lack of opportunity for advancement. The top three living conditions-related reasons for migrating were cost of living, public infrastructure, and the quality of consumer goods. Interviewees frequently cited an outdated cadre system as being a barrier to employing necessary personnel, and to advancement for those who are employed. Twenty two percent of respondents reported experiencing some unemployment in the past five years. Fifteen percent of respondents described their current economic situation as “Good” or better and 23% described it as “Poor”. Regression analyses indicated that, after controlling for respondents’ age, gender, profession, years in practice, source of funding for training, and main sector of work (public vs. private), only age was a significant predictor of respondents’ intention to migrate. Older respondents were less likely to report an intention to migrate.Respondents reported being much more likely to receive or make inquiries about working abroad through colleagues in other countries than through recruitment agencies. One third of respondents reported having applied to write the licensing exam for their profession in another country.

Eleven percent of respondents reported having worked in their profession in another country, mostly other Caribbean countries, and returning. Most of these respondents reported being unsure whether their returns were permanent.

Interviewees reported that HRH who migrate tend to be more experienced, which reduces the leadership and mentoring skills available to those who remain. Respondents described international HRH migration as having a more negative impact than rural to urban or public to private sector migration. Eighty percent of respondents said they would send money home to Jamaica if they did migrate. Remittances from all Jamaicans living abroad are estimated at $2B USD or 1/7th of Jamaica’s GDP.

Jamaica has implemented a number of domestic and international strategies to mitigate the negative impacts of HRH migration. However, the impacts of these programs are unknown.

Conclusion

Although its current health information systems preclude a precise quantification of the extent of HRH migration, it is clear that migration is very common among Jamaica’s health care personnel. It is also clear from published literature as well as the study participants that the causes of migration in Jamaica are numerous, long-standing, and systemic. Unfortunately, deeper understanding of the causes and consequences of migration, as well as the various strategies implemented to mitigate those consequences, is hindered by a variety of factors. These include weak health information systems (HIS) and infrequent policy evaluation. Recent efforts by Jamaica’s Ministry of Health, in collaboration with other partners, to strengthen its HIS, update its HRH cadre, and increase its capacity for HRH research and policy evaluation may help to address these issues.The study was limited by a low response rate to the survey of health personnel. There were 361 respondents to the survey. Although accurate data on the number of licensed health personnel currently in Jamaica are not available, the estimated size of the potential respondent pool across the four targeted professions is just under 6,000. This makes for a response rate of less than 10%. That said, the findings of the study were validated by a range of Jamaican stakeholders as being consistent with their experience. Further, it was noted by participants at the international forum that many of the findings from Jamaica were consistent with those from the other participating ‘source’ countries. This indicates that its results have national and global validity, strengthening the case for their incorporation into Jamaica’s HRH policy.

This study tries to understand the complex phenomena related to the governance of immunization services in Kerala, India where, after basic immunization reached high coverage in the late 1990s, started to decline in some of the regions. The study applied system thinking lens and used a qualitative case study approach to explore the underlying phenomena governing vaccination coverage in two districts in Kerala, one with high and one with low coverage. The study identified four phenomena that influenced change in vaccination coverage.

Background

Governing immunization services in a way that achieves and maintains desired population coverage levels is complex as it involves interactions of multiple actors and contexts. The conventional approaches often fail to take this complexity into account and expect that technically sound programs ensure successes when necessary management processes are in place. In India, the Universal Immunization Program (UIP), introduced in 1985, targets around 27 million infants and 30 million pregnant women every year and is one of the largest in the world. In one of the high performing Indian states, Kerala, after basic immunization had reached high coverage in the late 1990s, it started to decline in some of the regions.

Objectives

We applied a systems thinking lens to understand the contexts, processes and complex phenomena which led to changes in vaccination coverage over the past three decades in Kerala and the reasons underlying these changes. The analysis expands our understanding of the governance of immunization programs operating in a complex system and thus, enables an understanding of, not only for Kerala but also for the other contexts, where public health programs are showing similar complex behavior.

Methodology

We used a qualitative case study approach to explore the underlying phenomena governing vaccination coverage in two districts in Kerala, one with high and one with low immunization coverage. Data collection included in-depth interviews with private and public providers; beneficiaries and other stakeholders, as well as focus group discussions with mothers of under-five children and observations of vaccination-related activities. Content analysis for the qualitative data aimed to identify and describe the complex, adaptive phenomena resulting from immunization programs in our study area. Causal loop diagrams were developed to depict the phenomena, key actors, and their interactions.

Results

We identified several complex phenomena that influenced change in vaccination coverage levels in the two districts. For example, we identify a phase transition from acceptability to resistance of receiving vaccination services due to the involvement of new actors. The causal loop diagram illustrated several balancing and reinforcing feedback loops that resulted from actions of actors attempting to regain vaccine acceptability and others who counteracted these actions. For instance, mothers who played a major role in decision making during the acceptance phase were replaced by the male members of the household during the resistance phase. The male members were influenced mainly through media which used a negative incident related to child vaccination to create a polemic that influenced their behavior and stance with respect to child vaccination all together. The conventional public health approach that is designed to target mothers through health information and female community health workers did not manage to counteract the influence of media since they are not designed to directly target the male members of the household.Path dependence is another phenomenon where new events influenced the way the decision to vaccinate by households was shaped in two different regions and the speed by which this happened. For instance, the special vaccination campaigns where the entire state machinery mobilized its resources to increase smooth operations were seen as a soft target by groups among naturopathy and homeopathy systems that traditionally opposed vaccination and propagated their misgivings against immunization programs. Finally, the emergence of social networks and their power to influence the change in either direction was detected. Health Worker’s status as a local woman known to the other members of the community gives her special advantage in influencing community perceptions on immunization issues

Conclusion

This study offered a rich understanding of the interactions between multiple actors and contexts and the various phenomena that resulted from these interactions, influencing households' decision to vaccinate their children. Understanding these interactions, including the power exercised by each actor at different points in time, the factors determining the exchange of information, and the norms guiding the institutional mechanisms for immunization functions, clarified how the societal actions changed from acceptance to resistance to vaccinate. Understanding vaccination coverage using a systems thinking lens offered a robust framework to explore the underlying complex mechanisms and contexts that influence policies. The framework also emphasized the importance of considering all the actors beyond health systems. It can be applied in other public health contexts to define problems and guide the analysis.

Diabetes is a global epidemic that has traditionally lacked proper attention, a situation the International Diabetes Federation (IDF) is working to revert through integrated advocacy and communication efforts. IDF pushed for a UN High-Level Meeting on Non-communicable Diseases, held in 2011 and resulted in a Political Declaration on NCD prevention and control, placing diabetes high on the global health agenda. IDF also implements campaigns such as “Take a Step for Diabetes” to raise awareness on diabetes to an increasingly broader audience thanks to social media. The combined advocacy and communications efforts result in campaigns to help reduce risk factors and raise awareness on diabetes.

Background

Diabetes and Noncommunicable Diseases (NCDs) are the leading cause of death and disability worldwide - accounting for 34.5 million of the 52.8 million global deaths in 2010 (65%). They exact a heavy and growing toll on physical health, economic security and human development.A global epidemic at crisis levels, diabetes affected 371 million people in 2012 and the number is due to increase to 552 million in 2030.The United Nations Political Declaration on NCD Prevention and Control raised diabetes/NCDs to the top of the international agenda and led to the adoption by the 66th World Health Assembly (WHA) of the Global Monitoring Framework (GMF). This sets out 25 indicators to monitor progress towards the achievement of nine voluntary global targets by 2025 – including halting the rise in diabetes and obesity.

Therefore, advocating for health strategies and promoting social mobilisation to decrease NCD risk factors is vital. This can be achieved through awareness-raising communications that will have a positive effect on improving both diabetes/NCDs management and preventing the rise of new cases of diabetes and NCDs.

Objectives

Despite its consequences, diabetes continues to lack proper attention: half of all people with diabetes in 2012 – a shocking 186 million – were undiagnosed and type 2 diabetes is increasing worldwide at an alarming rate. Raising awareness of the risk factors and promoting healthier lifestyles have the double impact of improving diabetes management and halting its rise.
The International Diabetes Federation (IDF) – whose mission is to promote diabetes care, prevention and a cure worldwide – has two objectives to revert the present situation: advocate for political commitments and increase public awareness.INFLUENCING POLICY
In 2009 IDF, the Union for International Cancer Control, the World Heart Federation and the International Union Against Tuberculosis and Lung Disease formed the NCD Alliance (NCDA), a highly influential civil society force focused on placing non-communicable diseases (NCDs) on the political agenda.
IDF and NCDA have engaged in high-level advocacy to achieve this effect. IDF and NCDA campaigned for a UN High-Level Meeting on NCDs, held in September 2011 which was a major milestone in the history of diabetes and other NCDs. During the Summit IDF and NCDA influenced political negotiations to secure strong outcomes for diabetes and NCDs. The unanimously adopted Political Declaration on NCD Prevention and Control, opened the door for further advocacy efforts towards a Global Monitoring Framework (GMF). This was finally endorsed by the World Health Assembly in 2013. The GMF has 25 indicators to monitor progress to the achievement of nine voluntary global targets by 2025 – including halting the rise in diabetes and obesity.
IDF and NCDA’s work does not finish with the adoption of these global targets. IDF, its Member Associations and NCDA continue to work to monitor the progress governments make on their promises and to press the case for including NCDs in a global development framework post-2015.SOCIAL MOBILISATION
Despite the political will to stop the current diabetes epidemic that is reflected in the adoption of these nine voluntary global targets, there must be more advances. There will be no change unless both people with diabetes, and those at risk of developing the condition, are aware of the risk factors and willing to adopt healthier lifestyles. With that objective IDF has set in motion the social mobilisation campaign “Take a step for diabetes”, as part of the 5-year World Diabetes Day theme “Diabetes: education and prevention”.

Methodology

Over the last four years World Diabetes Day has focused on raising awareness of the warning signs and risk factors of diabetes, highlighting the serious global threat that it poses, promoting simple and cost-effective measures to prevent the further rise of type 2 diabetes and the importance of diabetes education from a young age.With the goal of keeping the global commitments on diabetes made during the 2011 UN Summit on NCDs on the global health agenda, IDF launched the 2013 campaign “Take a Step for Diabetes” in March 2013, marking the final year of the “Diabetes: education and prevention” campaign.Conceived as a new way of raising awareness, inspiring local communities and promoting membership “Take a Step for Diabetes” has been designing as an innovating, engaging programme. It encourages people to make a symbolic donation of steps accrued through activities that help promote diabetes awareness, improve the lives of people with diabetes, promote healthy lifestyles or reduce one’s individual risk of developing diabetes. A total of 32 activities – ranging from wearing blue to running a marathon – can be done repeatedly. The aim is to reach 371 million steps – one for each person with diabetes in the world.

The main target groups are IDF member associations, other diabetes-related organisations, young leaders in diabetes, health professionals and community groups promoting healthy nutrition and physical activity. However, everyone – individuals and groups - is invited to register on the campaign website (steps.worlddiabetesday.org) and submit steps, providing a short description of the activities performed. The steps are collected on an online platform that displays the total number of steps submitted and the gap to the 371 million target.

This campaign is widely promoted through all IDF communication channels: website, social media (Facebook, Twitter, YouTube), newsletters (IDF, World Diabetes Day, World Diabetes Congress) and events where IDF has a stand. Specific communication materials have also been developed for the campaign including web banners, promotional videos, posters promoting key messages, a smartphone application, merchandise and an online toolkit providing information and resources on diabetes.

The “Take a Step for Diabetes” campaign will be widely promoted in the run up to and on World Diabetes Day – November 14 – and will officially end at the World Diabetes Congress Melbourne 2013 – 2-6 December.

Results

The IDF campaign “Take a Step for Diabetes” has been designed to reach not only people and organisations strongly connected with diabetes – IDF regions and member associations, other diabetes-related organisations, community groups active in promoting healthy lifestyles, young leaders in diabetes, health professionals – but everyone who is interested in promoting the diabetes cause and furthering IDF’s mission.One of the campaign’s goals is to involve as many people as possible. The use of social media – mainly Facebook and Twitter – is essential in reaching a broad audience and engaging new publics in constructive dialogue. With more than 21.000 fans on Facebook and 13.000 followers in Twitter informed daily about the campaign, “Take a Step for Diabetes” has proven to be a powerful instrument for social mobilisation.More traditional means of drawing attention to the campaign are also used: the WDD newsletter had over 25.000 subscribers in September 2013 and, since the launch of the campaign in March the WDD website had achieved more than 100.000 views.

By the end of September 2013 over 450 individuals and groups had registered on the campaign online platform and performed around 8000 activities, accruing more than 332 million steps. The achievement of 90% of the target, 371 million steps by December 2013 which is 3 months in advance of the deadline, reflects the campaign’s impact and success.

However, as IDF is encouraging its member associations and other organisations and groups to organise WDD awareness activities – particularly during the month of November and WDD (November 14), a significant hike in the submitted number of steps is expected around those dates. Considering that the initial 371 million steps target will possibly be achieved before then (October), and the campaign does not end officially until the World Diabetes Congress 2013 in December, it is likely that IDF may increase the current steps to make the goal more ambitious.

Once the target is achieved and the campaign is over, IDF will send an open letter to the United Nations Secretary General Ban Ki-Moon on behalf the “Take a Step for Diabetes” participants. The great social mobilisation achieved through this campaign will be used to advocate for the global commitments on diabetes made during the 2011 UN Summit on NCDs to be kept on the global health agenda.

Conclusion

Diabetes is a massive global burden with brutal health and socio-economic consequences. Although type 2 diabetes – which accounts for the vast majority of the cases worldwide – is largely preventable, the number of affected people is increasing in every single country. Tackling the current situation is a health priority for which interdisciplinary collaboration is imperative.Advocacy and communication are two inextricably linked working areas with the common objective of raising awareness. While advocacy is focused on influencing governments and key authorities to develop more comprehensive policies and strategies, communication promotes dialogue by delivering a series of messages to the general public. Both of them have a big role to play in overcoming the diabetes epidemic.The foundation of the NCD Alliance, of which IDF is founding member, was a clear advocacy milestone in combatting the NCDs and diabetes outbreak. As a network of more than 2,000 organisations, the NCDA is using its powerful voice to press governments into giving urgent response to NCDs as was shown by the UN High Level Meeting in 2011. The adoption of the GMF with its nine voluntary global targets to achieve by 2015 is another NCDA victory.

Political commitments on diabetes and NCDs are of great importance but would have little impact if the population is not aware of the risk factors to which we all are exposed. Communication campaigns such as “Take a Step on Diabetes” are perfect tools to promote healthy lifestyles and raise awareness on those risk factors. Social media has meant a revolution in this discipline, as now it is possible to reach a much broader audience than previously. In addition, an engaged population is another influential force for holding governments accountable for their political commitments.

Advocacy and communication are continuously interacting and frequently the outcome of one discipline can be used as a tool by the other. On the occasion of the achievement of the “Take a Step for Diabetes” campaign target a letter will be sent to the UN Secretary General Ban Ki-Moon, to continue advocacy efforts on keeping diabetes and the NCDs high on the political agenda. The constant feedback between advocacy and communication is a mechanism that needs to be continuously strengthened, to ensure the best outcomes in the fight against diabetes and NCDs.

Background: Malnutrition in Children is extensively prevalent in India. Poor feeding practices may lead to the burden of malnutrition, infant and child mortality.Objectives: To create awareness and demand generation in the community of government health services for infant and child feeding practices with the help of Information Communication Technology (ICT)Methods: Centre for Development of Advanced Computing and the Ministry of Communications and Information has developed the ‘MOTHER’ tool to capitalize the mobile phone’s core utility of ‘voice calls’ to create health awareness among the illiterate rural community. The project was taken up where the 80% of the population owned mobile phones.

What challenges does your project address and why is it of importance?

•Registration and updating of the beneficiary records in the ‘MOTHER’ system directly from remote locations was a big challenge owing to poor internet connectivity. Our field workers started collecting the beneficiary details manually in the prescribed registration forms and in the evening, records were updated online from the Mandal Headquarters.• Voice alerts are being pushed from the system to the beneficiary mobiles and it is unilateral communication (Push Method). Beneficiary can’t call back and interact with the system. To facilitate the beneficiaries queries the phone numbers of health officials of the PHCs have been circulated to the beneficiaries during registration.
•In many families, mobile phones are only with husbands who receive the voice alerts. Most of the husbands are not interested in knowing about the basic support that can be provided to women during pregnancy and child care. They feel that it is the duty of the women. Sensitizing the husbands was one of the major challenges faced by our team. As part of MOTHER project, we organized village level awareness meetings to sensitize the men to listen to the voice alerts and pass the information to their wives.
•Compared to SMS, voice calls are costlier.

How have you addressed these challenges? Do you see a solution?

Challenge: Registration and updating of the beneficiary records in the ‘MOTHER’ system directly from remote locations was a big challenge owing to poor internet connectivity. The solution was that our field workers started collecting the beneficiary details manually in the prescribed registration forms and in the evening, records were updated online from the Mandal HeadquartersChallenge: Voice alerts are being pushed from the system to the beneficiary mobiles and it is unilateral communication (Push Method). Beneficiary can’t call back and interact with the system.Solution: To facilitate the beneficiaries queries the phone numbers of health officials of the PHCs have been circulated to the beneficiaries during registrationChallenge: In many families mobile phones are only with husbands who receive the voice alerts. Most of the husbands are not interested in knowing about the basic support that can be provided to women during pregnancy and child care. They feel that it is the duty of the women. Sensitizing the husbands was one of the major challenges faced by our team.
Solution: We organized village level awareness meetings to sensitize the men to listen to the voice alerts and pass the information to their wives.
Challenge: Compared to SMS, voice calls are costlier. Moreover, service providers charge based on call duration and number of calls made per month.
Solution: We designed the voice alerts such a way that each call will be less than one minute and each alert will be sent two times in a day. Only critical alerts (such as expected date of delivery) will be repeated more than 3 times.

How do you know whether you have made a difference?

Who were targeted:
• pregnant women, husbands of beneficiaries, fathers of children, health care providers,
Why:
• To create demand for the health services in the community, better utilization of health services by the beneficiaries and timely monitoring by the health officials.
How was this delivered:
• Apart from better infant and child feeding practices as presented in the abstract we observed positive changes after implementations of the project.
• Repeated voice calls sensitized the family members, particularly husbands, to understand the importance of pregnancy and the care to be taken at critical stages. Improved participation of husbands and fathers in health care activities was observed.

Have you or the project mobilized others and if so, who, why and how?

The project mobilized community participation and awareness created by the project helped to create demand for health services, especially for immunization as the Mother call voice alert reaches the beneficiary (pregnant women, Mother's of below 18 months) on the days of immunisation schedule as well as nutritional supplementation through the Integrated Child development Surveillance program. Beneficiaries were demanding the village health workers for immunization and the food supplements such as Egg, fruit and calorie and protein mix.It also helped to improve health workers participation as it increased the responsibility of Health workers to follow-up with registered members. The number of visits by health workers to the beneficiary house reduced, in turn helping them to effectively utilize their time in other productive works. As to corruption, beneficiaries were sensitized about the entitlements and monetary benefits from health department along with voice health alerts. The better utilization of health as well as monetary benefits was observed.There was online monitoring of the beneficiaries details by higher government health authorities especially about high risk cases of pregnancy.

When your donor funding runs out how will your idea continue to live?

In spite of a few limitations and challenges faced by the Mother tool implementation, the Mother project is a successful program that creates awareness on infant and child feeding habits. The Mother pilot project has been initiated with the goal of being integrated into the national level health services, so the pilot has been implemented by involving State National Rural health Mission and the antenatal and child data collection formats used in mother project were also of National Rural health Mission (NRHM) as these formats are common across the country. The NRHM people were involved at each step of the implementation program which helped the Mother project to be taken up by the state NRHM. The scale up of the Mother project to state level has been assisted by the NRHM officials involved witnessing the effectiveness of this innovative tool to create awareness across community, in particular to rural illiterate women. At the National level NRHM is considering a scale up to entire nation in a phased manner. Considering the level of mobile penetration in India and literacy level among rural women, voice calls (MOTHER) is the best model to reach-out towards the target beneficiaries directly at an affordable cost. The projected has been scaled up to the state level and National Rural Health Mission is adopting this tool and scaling up to the different states in phases at national level. This project has been awarded "eIndia 2012’ Public Choice Award under Health category.

The present study aimed to examine the determinants of using traditional medicine by different socio-economic groups of people, assess the marketing strategies of providers of traditional medicines, and look at the existing policies that regulate the production, marketing and supply of traditional medicines. Household survey, exit client survey and key informants interview were employed to collect data. The findings suggest that though traditional medicine is popular in both rural and urban areas, inadequate monitoring and poor implementation leads to improper preparation of medicine with low quality or even the manufacturing of such medicines without legal permission.

Background

Traditional medicine is the sum total of knowledge, skills and practices based on the theories, beliefs and experiences indigenous to different cultures that are used to maintain health, as well as to prevent, diagnose, improve or treat physical and mental illnesses. In Bangladesh, traditional health care providers (ayurvedic, homeopathic, unanie/kabiraji and others) are common and popular in rural areas leading to low utilisation of public facilities. It is evident that the non-availability of drugs and commodities, poor access to services by the poor, imposition of unofficial fees, lack of trained providers, a rural-urban imbalance in health providers’ distribution, weak referral mechanisms and unfavourable opening hours are contributing to low use of public facilities in Bangladesh. This indicates that though the health care seeking behaviour is partly associated with the socio-economic status of the population, the supply side problems existing within the health system also influence service utilization. In this context, the present study aimed to examine the determinants of using traditional medicine, assess the marketing strategies of providers of traditional medicines and to look at the existing policies to regulate traditional medicine.

Objectives

The present study aimed to examine the determinants of using traditional medicine by different socio-economic groups of people and assess the marketing strategies of providers of traditional medicines. The specific objectives are to:• Assess the perception of people about safety, efficacy and quality of traditional medicine
• Identify the reasons for preferring traditional medicines by their types and by different socio-economic groups of people, and the types of services received
• Explore the level of satisfaction of users by socio- economic category, age, and gender
• Investigate the marketing strategies of providers for selling traditional medicines
• Identify the national policy and existing regulatory mechanisms for traditional medicines

Methodology

The study followed a cross sectional survey approach where both quantitative and qualitative data was collected from exit clients, providers and at the household level at a single point of time. The study was carried out in two districts: Tangail and Munshiganj. Two upazilas from each district had been chosen randomly. Household surveys were carried out to assess the extent to which people from different socio-economic groups prefer traditional medicine and the reasons for preferring traditional medicine. Household surveys gave an overall understanding of the preference for traditional medicine among the population. A total of 800 households were surveyed from the four upazilas, taking 200 from each upazila. Among the households, 400 households were selected from rural poor areas and 400 from urban/peri urban non-poor areas to include samples from different socio-economic groups. A multi-stage stratified systematic random sampling approach was adopted. Wards were selected as Primary Sampling Units (PSU) through a systematic random sampling procedure from the list of wards as documented in Community Series Population Census 2001, published by Bangladesh Bureau of Statistics. After selecting the sample wards as the PSUs, we again adopted a systematic random sampling technique to draw sample households from the wards. We followed a cluster randomization approach for selecting the households within the sample frame. A semi-structured questionnaire was used for the household survey. Randomly selected 20 exit clients of each type of traditional medicine users (160 clients from eight facilities/providers) were interviewed to assess their knowledge, attitude and practice regarding traditional medicine usage, and their level of satisfaction. This contributed to the gathering of a more specific understanding of the preference for traditional medicine among the users. A semi-structured questionnaire was used to collect data. We interviewed three policy makers within the Directorate General of Health Services and one academic. A total of 18 traditional medicine providers were also interviewed for the study. The quantitative data were analyzed by using both descriptive and analytical statistics. Transcribed qualitative data were analyzed with respect to context, process, and outcomes.

Results

Traditional medicine was popular among households in study areas. Overall, 48% of the households sought treatment from traditional providers in the recent past for themselves or for any one of their family members in the study areas, while the proportion was relatively higher in Tangail (54%) as compared to Munshigonj (42.5%). It was also found that the proportion of households who used traditional medicines were higher in Sadar upazilas (51%) as compared to the remote upazilas (45%). It was evident that 47% of households who had sought treatment from traditional providers were poor defined as those whose monthly household income was less than 10,000 Taka. Households sought treatment from traditional providers generally for women and children, who suffered from fever, pain, common colds and general ailments such as anemia, helminthiasis and nutrition, eye infection, common dental diseases and ear problems. The percentage of households inclined to take treatment from traditional providers for the elderly was relatively low in both areas (15% in Tangail and 11% in Munshigonj), and a few of them sought treatment for non – communicable diseases such as diabetes, cardio-vascular disease, hypertension, heart diseases and hypertrophy of the heart. The major reasons for seeking care from traditional providers were low cost, no side effects, prompt services and most importantly the close location of the service centre which makes the service easily accessible. It was found that illiterate and little learned persons were the main clients of traditional medicine. A considerable number of exit clients were found to be familiar with traditional medicine and had been using it for quite a long period. Therefore, from the view point of effectiveness, the clients were satisfied with traditional medicine. Most of the clients of both districts claimed that they never had any side effect for using traditional medicine. Providers also distributed leaflets in popular public places, did promotion on TV through cable operators and made miking and wall paintings to attract less-educated and middle income group people. It was evident that though there exists law and policy regarding production and practice of traditional medicine in Bangladesh, the poor implementation of the law and inadequate monitoring leads to improper preparation of medicine with low quality or even the manufacturing of medicines without legal permission due to the unavailability of proper medicine testing laboratories for traditional medicines.

Conclusion

Traditional medicines are believed to be made of natural products and therefore are safe and have no side effects. However, traditional medicines and practices can be harmful if the medicines are inappropriately prepared and consumed. For mainstreaming the traditional medicine into the public health system, the followings measures need to be adopted:• A proper regulatory framework is required for the quality production and safe use of traditional medicine in Bangladesh. Given the heterogeneity of the service provision by the traditional providers, a monitoring and regulation mechanism needs to be developed to ensure quality of service provision. Governments should take the necessary measures to strengthen drug administration to ensure the quality of traditional medicine.• An appropriate medicine testing laboratories service must be introduced to ensure the quality of Unani, Ayurbedic and Homeopathic medicine.• Government needs to establish training centres for service providers and manufacturers of traditional medicine.

• Initiative should be taken by government and NGOs to increase awareness among the population about the service variety and quality of traditional medicine.

• Further research should be done on the cost-effectiveness of traditional medicines, pharmacology of natural products, characterization of natural products, synthesis of natural products, product development and possibility of commercialization of traditional medicine.

Snakebite envenoming is one of the most neglected public health problems in poor rural communities living in sub-tropical and tropical regions. In Nepal, proper management of snakebite envenoming relies on rapid access to a health facility where trained staff are able to administer antivenom and provide ventilatory support. Here, we report on an integrated care approach by which paramedics in the region were empowered in the prevention, management and research of snakebite envenoming.

Background

Despite recent community-based data demonstrating the high burden it causes on health, snakebite has received little attention from stakeholders. South Asia is the world’s most affected region, with reported annual incidence and mortality rates of up to 1,162 and 162 per 100,000 population in rural southeastern Nepal.

Objectives

We aimed to develop an integrated care approach by empowering paramedics in the prevention, management and research of snakebite in the region

Methodology

Community-based surveys, an intervention study, prospective and retrospective hospital-based surveys, a prospective observational clinical study and a randomized controlled trial were conducted to integrate different prospect of snakebite related issues in rural area of eastern Nepal.

Results

Snakebite victims’ first encounter with the health care system in rural Nepal is with sub-health posts or primary health centers, where facilities for antivenom administration are non-existent. Access to adequate care is often not possible at secondary or even tertiary health care centres, from where patients are in fact sometimes referred to from smaller centres that are entirely specialized in the management of snakebite. In the absence of sufficient human resources to manage snakebite in rural Nepal, we aimed to develop an integrated care approach by empowering paramedics in the prevention, management and research of snakebite in the region. Rapid transportation of victims by motorbike to a specialized snakebite treatment centre was identifed as a key life-saving measure in southern Nepal and a volunteer program was subsequently set up in this region. Research efforts have then focused on (i) the identification of snakes that bite patients in this region, (ii) the development of rapid diagnostic tests to identify the species of biting snakes and (iii) optimizing the dosage of antivenoms.

Conclusion

The development of simple diagnostic tools and evidence-based antivenom dosage and ancillary treatment guidelines should facilitate the integration of snakebite management in the public health system as well as in the specialized centers run by paramedics. These efforts should be complemented by the routine integration of pre- and post-graduate training of healthcare personnel in snakebite management and an adequate commitment of medical authorities at both central (e.g., purchasing and deployment of free-for-patients antivenoms) and peripheral levels.

Tobacco use is one of the leading causes of early deaths and is gradually increasing in developing countries like Bangladesh. Bangladesh is on the verge of tobacco epidemic as 16% of total deaths among the people aged 30 years and above is connected to tobacco use. There are many difficulties in mitigating the tobacco menace in Bangladesh despite government laws and regulations. Community level effective communication strategy/techniques were largely absent in providing meaningful information about the harmful effect of tobacco use. icddr,b has develop and tested a package of communication techniques to reduce tobacco use at the community level.

Background

Tobacco use has long been a leading contributor to premature death, and causes about 9% of deaths worldwide. Rates of smoking are increasing in many low-income and middle-income countries including Bangladesh. The proportion of tobacco-attributable deaths from tobacco use increases as the number of deaths increases. According to WHO, nearly 6 million people die from tobacco-related causes every year. If present patterns of use persist, tobacco use could cause as many as 1 billion premature deaths globally during the 21st century. Tobacco use, in particular smoking cigarettes and bidis, are common habits among the general male population in Bangladesh. Smoking related diseases such as pulmonary diseases, stroke, ischemic heart disease etc. are well documented. Smokers have a greater risk of dying from pulmonary tuberculosis as compared to non-smokers. Tobacco related illnesses accounted for 16% of the total deaths among the population of Bangladesh who are aged 30 years and above, which is about 25% of deaths in men and 7.6% in women. Smoking is also positively linked with the illicit drug use in Bangladesh. The cost of tobacco consumption at the national level is found to be associated with the increased health-care costs and loss of productivity due to illnesses and early deaths.

Objectives

The objectives of the project are to document the effectiveness of various communication techniques in reducing the tobacco use in a targeted population and design a future intervention based on the effective techniques.

Methodology

The project carried out in Chakaria, a rural sub district of Cox’s Bazar in Bangladesh where icddr,b is active in research and development activities since 1994. Fifteen villages from three unions were selected for the intervention and the same number were chosen for comparison. We have adopted various interventions in the form of Othan Baithaks or household courtyard meetings, peer group meetings, transmitting cell phone messages, counselling tobacco users through mobile phones and motivating village doctors to disseminate messages to the patients. The target audience is women and men aged 15 years and above. During the intervention, a female/male health worker showed/discussed the potential harmful effects of smoking and the dangers of passive smoking, emphasizing the idea that smokers not only put themselves at risk of serious health problems but also the people around them who are mainly family members. The health worker also transmitted the messages to all mothers that a developing baby can be affected by tobacco smoke if the mother smokes or if she is exposed to tobacco smoke during pregnancy. A video showing the harmful effects of tobacco use and large pictorial messages were displayed to communicating the message to smokers and non-smokers. Data were collected from follow-up, and mobile counselling, video sessions and process documentations were used for analyzing and interpreting the results.

Results

During January 2011-June 2103 intervention period total 9760 women/men aged 15 years and above from 1600 households participated in the Othan Baithaks and organized video sessions. 1482 households had mobile phones and 78% of these households were contacted for counselling through mobile phone. Among the population, men were most likely to use tobacco than women. Among the targeted population 1173 (12%) quit tobacco, 728 (7.5%) committed to quit and 1482 (15%) persons reduced the use of tobacco compared to their daily uptake.

Conclusion

Community level intervention can be an effective mechanism to reduce tobacco use along with government regulatory measures to combat tobacco menace. The regulatory framework can be designed such a way that the community can be engaged, informed and create a platform to use this as a prevention strategy.

ASHA (meaning Hope in Hindi) is a program of Accredited Social Health Activists who works at basic grass roots level in one of the world's largest healthcare programs, NRHM- National Rural Health Mission. The present study was carried out in Bagli block (primarily a tribal block) of Dewas district of Madhya Pradesh (state with highest Infant Mortality Rate= 56 in India) to evaluate ASHA based on the 8 factors critical for success of ASHA identified by Government of India.

Background

ASHA is a program of grass roots workers under NRHM (National Rural Health Mission), the largest health care program of the Government of India which started in the year 2005. ASHA are female health activists in the community who creates awareness on health and its social determinants and mobilizes the community towards local health planning and increased accountability of the existing health services. The 8 factors identified by the Government of India critical for the success of ASHA are 1. Selection of ASHA by a prescribed process as per the ASHA guidelines. 2. Linkage with nearest functional health facility for referral services. 3. Identified transport for referral of cases from village to facility. 4. Priority and recognition of cases referred by ASHA to MO/ANM. 5. Successful organization of monthly Village Health Sanitation and Nutrition Committee (VHSNC) and Village Health Sanitation and Nutrition Day (VHSND) in every village with the ANM ( Auxiliary Nurse Midwife) and AWW (Angan wadi worker). Angan wadi is the basic unit of Govt. of India ICDS (Integrated Child Development Scheme) 6. Monthly meeting of ASHA at PHC. 7. Timely payment of incentives to ASHA. 8. Timely replenishment of ASHA Kit.-which contains 13 Items.

Objectives

Broad Objective
To evaluate the function, knowledge & skills of Accredited Social Health Activist (ASHA) in a tribal block of a state with highest Infant Mortality Rate in India.
Specific Objectives:
To study the working of ASHA & identify the problems experienced by them within their workplace.
To assess the knowledge & skills of ASHA.
To study the training status of the ASHA.
To assess the beneficiary satisfaction of ASHA as experienced by Community .
To identify recommendations based on present study.

100% ASHAs were the primary female residents of the village that they had been selected to serve.
84% are married, 12% are widowed and 4% of ASHAs are divorced.
4% are graduates, 14% are 10th grade pass, 82% are 8th grade pass.
26% are in age group 25-29 years, 58% are in age group 30-34 years and 16% were from 35 years to 45 years.
100% ASHA had good rapport with ANM (basic health worker posted at Sub Health Center & Primary Health Center) & AWW (Anganwadi worker – basic nutrition worker posted at Anganwadi Center which is the basic nutrition centre located in a population of 1000 in both rural & urban areas.)
100% ASHAs mobilizes the community and facilitates them in accessing health and health related services available at the village such as the Sub Health Center & Primary Health Center.
All the ASHAs (100%) coordinate with 108 Emergency Ambulance and Janani Express obstetric care Ambulance for referral of cases from villages to healthcare facility.
In 93% of the villages the Village Health Sanitation and Nutrition Committee is operational to deal with health & Nutrition issues. Sanitation is covered only in 7% villages in the present study.
Out of the 13 items to be provided in ASHA Kit, 12 were present in 95% ASHAs- DDK (Dai Delivery Kit ) which were for delivery at homes: Tab. Iron Folic Acid, Zinc based ORS Packets, Tab. Paracetamol, Tab Dicyclomine, Providine Ointment Tube, Thermometers, Cotton Absorbent Roll, Bandages (4cm x 4 meters), Tab. Chloroquine, Condoms, Oral Contraception Pills. The only item not found in the ASHA Kit during the present study was Tab. Punarvadu Mandur (ISM Preparation of Iron).
100% ASHAs complained of irregularity in the timely incentive payments of ASHAs.
100% ASHAs were trained in all the 7 mandatory modules of ASHA Training.
In 100% of the villages the beneficiaries were satisfied by the work of ASHAs in the community experience.

Conclusion

In present study the ASHAs were married, widowed & divorced because according to Indian cultural norms after marriage a woman leaves her father’s house (and village) & migrates to that of her husband in accordance with the selection norms laid under NRHM. As per criteria ASHAs should be minimum 8th grade pass which was 82% in the present study. The maximum (94%) were in the 25 to 35 age bracket which is in lines with the criteria of age group 25 to 45 years according to NRHM. It is worth noted that, for selection of ASHA as per guidelines, Gram Sabha (Democratically elected local village body) or VHNSC recommends five names of suitable candidates to the Block Medical Officer (BMO). Appointment letter is issued by the BMO. Since VHNSC is not fully operational in most of the 30 villages, all the 50 ASHAs in the identified villages were selected by Gram Sabha. The 4 most common reasons for Community Mobilization for Health and Health related services by ASHA in order of frequency are as follows: immunization, antenatal care check-up, nutrition related problems and postnatal care check-up. There is no Community Mobilization by ASHA for sanitation and related services. The 108 Emergency Ambulance & Janani Express Obstetric Care Ambulance has connected almost every village to health facilities. At present in Bagli Community Health Center (CHC) there is 1 BLC (Basic Life Care) 108 and 1 Janani Express Obstetric Care Ambulance in Udai Nagar Tribal Primary Health Care Center. In Dewas District (under which Bagli is one of the Blocks) there is only 1 ALC (Advance Life Care) 108. The most common reasons for the referral of cases by ASHA to Medical Officer/ANM in order of frequency are: pregnancy and pregnancy related, GI (Gastro-Intestinal) related problems and respiratory tract infections. Recently the NGOs have trained the 7th comprehensive module to all the ASHAs of the identified villages. In all the villages the community was completely satisfied with the work of ASHA.